Hemostasis and

Transfusion Medicine
PGI Jesserene M. Soriano
Hemostasis and
Coagulation
Hemostasis
Primary Hemostasis
and
Coagulation Secondary Hemostasis

Fibrinolysis

Laboratory Evaluation of
Hemostasis
Primary Hemostasis
Mechanisms of Antiplatelet Medications

• Platelet adherence: NONE

• COX-1 inhibition: Aspirin and Trifusal
• ADP P2Y12 receptor blockade: Clopidogrel
• Protease-activated receptor-1 (PAR-1) blockade: Vorapaxar
• Platelet plug formation and stabilization blockade: Abciximab,
Eptifibatide, and Tirofiban (act at GPIIb/IIIa)
• Upregulation of major inhibitory pathway mediated by PGI 2:
Dipyridamole and Cilostazol
Secondary Hemostasis
Inhibition of Clotting Factors
Fibrinolysis
Laboratory Evaluation of PRIMARY
Hemostasis
• Normal platelet count: 150,000 to 400,000 /µL
• Microscopy

Clotted specimen Platelet clumping Giant platelet

Laboratory Evaluation of PRIMARY
Hemostasis
• In vitro platelet function tests: use various platelet agonists
to activate and aggregate platelets
• Platelet aggregation: most detailed overall PFT
Tested with multiple isolated agonists
Assesses patterns of physical aggregation and agonist release
• Electron microscopy: granule defects
• Flow cytometry: surface receptors and granule markers
• Genetic testing
Laboratory Evaluation of
SECONDARY Hemostasis
• Prothrombin time (PT)
extrinsic (tissue) and common pathway
activated by tissue factor
normal range: 12 – 15 seconds

• Activated partial thromboplastin time (aPTT)

intrinsic (contact) and common pathway
activated by negatively charged surface
normal range: 25 – 35 seconds
Laboratory Evaluation of
SECONDARY Hemostasis
• Fibrinogen assay
measures the functional conversion of fibrinogen to fibrin
fibrinogen level may also be measured
normal fibrinogen levels: 150 – 400 mg/dL
Laboratory Evaluation of
SECONDARY Hemostasis
• Mixing Studies
Laboratory Evaluation of
SECONDARY Hemostasis
• Activated clotting time (ACT)
point of care test
assesses the intrinsic clotting pathway
to monitor heparin anticoagulation and its protamine reversal during
cardiopulmonary bypass or vascular surgery
• Ecarin clotting time (ECT)
also describes intrinsic clotting function
primarily used for measuring the clinical effects of direct thrombin
inhibitors (DTIs) such as bivalirudin and dabigatran
Laboratory Evaluation of
SECONDARY Hemostasis
• Viscoelastic testing
measures the rate, strength and lysis of clot formation
via thromboelastography (TEG) or rotation thromboelastometry
(ROTEM)
helpful in the determination of appropriate therapy, including platelets,
plasma, fibrinogen replacement, or antifibrinolytics, particularly
complex bleeding syndromes such as massive haemorrhage with
consumptive or dilutional coagulopathy
Diagnosis of Thromboembolic
Disorders
• Thromboembolic disorders
Deep venous thrombosis
Pulmonary embolism
Venous thromboembolism

• Risk factors
physical inactivity or immobilization
malignancy
oral contraceptives
estogen therapy
pregnancy
CONGENITAL Risk Factors for
Thrombosis
• Factor V Leiden Mutation
most common hypercoagulable mutation
autosomal dominant mutation in Arg506Gln, rendering FV fairly
resistant to APC

• Protein C Deficiency
autosomal dominant
leads to overactive FVIII and FV
Type I: low activity and antigen
Type II: low activity with normal antigen levels
CONGENITAL Risk Factors for
Thrombosis
• Protein S Deficiency
autosomal dominant
can lead to thrombosis because of its cofactor role to protein C
Type I: total antigen is low
Type II: total antigen is normal; low function; rare
• AT-III Deficiency
relative lack of its normal blocking function on FVIIa, IXa, Xa and XIa
CONGENITAL Risk Factors for
Thrombosis
• Prothrombin mutation G20210A
guanine to adenine
autosomal dominant
best characterized congenital gain in thrombotic mutation
high circulating prothrombin levels
ACQUIRED Risk Factors for
Thrombosis
• Antiphospholipid A antibodies
associated with both arterial and venous thrombosis risk
bind to phospholipid-protein complexes
could directly initiate coagulation and/or cause vascular injury by
binding to and activating endothelial cells
interfere with phospholipids in the protein C-ase enzyme complex
• Hyperchromocysteinemia
due to congenital mutations in homocysteine’s metabolic pathways or
acquired via folate, B12, and B6 deficiency
intial screening test: Fasting total homocysteine
Monitoring Anticoagulation
Therapeutic Agents
• Warfarin
PT
International Normalized Ratio (INR)
 normalized value intended to compare results across laboratories
 warfarin-dependent factors: FII, VII, IX, X
 therapeutic range for warfarin: 2.0 – 3.0
 mechanical heart valves and prevention of myocardial infarction: 2.5 – 3.5
Monitoring Anticoagulation
Therapeutic Agents
• Heparin
aPTT
 therapeutic range: 1.5 – 2.5 times the normal mean
antifactor Xa assay (aFXa)
 therapeutic target heparin levels: 0.3 – 0.7 aFXa units/mL
 assessing heparin resistance
Blood
Component
Production
Blood
Blood Collection
Component
Production Component Processing and
Storage

Plasma Derivatives

Pathogen Inactivation
Blood Collection

• Whole blood donations: 450 – 500 mL; citrate

• Apheresis: donor’s blood is processed by ex vivo
centrifugation, desired component(s) are siphoned off into
citrate anticoagulant, and the remainder returned to the donor
• Screening: HIV, HBV and HCV
• Autologous donation
Hgb: 11g/dL
Hct: 33%
reserved for patients with difficult crossmatch problems
Component Processing and Storage

• Leukoreduction: removal of WBCs from RBCs and platelets to

reduce the risk of HLA alloimmunization, febrile nonhemolytic
transfusion reactions (FNHTRs), and CMV transmission
• Washing: saline; to remove plasma in patients with allergic
transfusion reactions
• Irradiation: exposure of units to gamma irradiation (2500 cGy)
to prevent transfusion GVHD
Component Processing and Storage

• Platelets: stored at room temperature to preserve clotting

function but increases the risk of bacterial growth in
contaminated units
• RBC preservation: CPDA
Citrate: anticoagulation
Phosphate: buffer
Dextrose (1 to 2 g)
Adenine
Plasma Derivatives

• albumin: for intravascular volume support and is pasteurized

at 60 deg C for sterility
• immunoglobulins: for immune support or immunomodulation
to suppress native antibody production
• factor concentrates: for patients with congenital factor
deficiencies
• complement C1 esterase inhibitor: for hereditary
angioedema
• α1-antitrypsin
Pathogen Inactivation

• Solvent-detergent treatment: for plasma

• Psoralen treatment: for plasma and platelets
• Membrane-disrupting solvent-detergent treatment: for
enveloped viruses in cell-free plasma
• Methylene blue, psoralen or riboflavin: bind to nucleic acids
when added to blood bag
Blood Products
and Transfusion
Thresholds
Blood Products
Compatibility Testing
and Transfusion
Thresholds
Red Blood Cells

Plasma Products

Cryoprecipitate

Fibrinogen Concentrate
Compatibility Testing

• ABO and RhD typing

• Antibody screen for IgG non-ABO antibodies
• RBC crossmatch

• emergency: uncrossmatched group O RBCs

Red Blood Cells
Physiologic Compensation for Anemia

• Increased CO
increased heart rate
increased stroke volume
• Altered microcirculatory blood flow
due to lower shear force in capillary bed
dilation of arterioles
increased angiogenesis and microcirculatory blood volume
• Increased tissue oxygen extraction
shift to the right of the oxyhemoglobin dissociation curve
increased 2,3-DPG
 Physiologic Compensation for Anemia

• rise of 1g/dL per 1

unit of packed RBC
• target haemoglobin
for acute
haemorrhage: 7-9
g/dL
Platelets
Platelets

• Average dose of platelets

one concentrate from apheresis donation
pools of five to eight concentrates from whole blood or buffy coat
collections
1 unit = 3x1011 to 4x1011 platelets
• Refractoriness at 20 to 24 hours
associated with older platelets or increased consumption secondary to
fever, infection, bleeding or medications
• Adjunctive therapy for platelet dysfunction
antifibrinolytics, DDAVP or PCCs
Plasma Products
• plasma contains all factors involved in hemostasis
• fresh frozen plasma: within 8 hours of collection
• PF24: plasma frozen within 24 hours of collection
• thawed plasma: units of frozen plasma thawed for more than
24 hours yet remain usable for up to 4 additional days
• has normal levels of stable factors and at least 70% normal
levels of labile factors (FVIII and FV)
• thawed at 30 to 37 deg C
• stored at 4±2 deg C for up to 24 hours (thawed FFP) or 5
days (thawed plasma)
Cryoprecipitate

• created by controlled thaw of FFP which allows for precipitation

of large molecules
• contains fibrinogen (about 15 g/L), fibronectin, vWF, FVIII and
FXIII
• single adult dose: five pools and frozen at -18 deg C for up
to 12 months
• 1 dose = increase of fibrinogen levels by approx. 50 g/dL
Fibrinogen Concentrate

• derived from plasma after several steps of viral inactivation that

also minimize antibodies and antigens
• lyophilized powder formulation
• stored at room temperature and reconstituted for administration
in less than 10 minutes
• safe, low-volume alternative to cryoprecipitate
• threshold for fibrinogen replacement: <80 to 100 mg/dL
The Risks of
Blood Product
Administration
The Risks of
Infectious risks
Blood Product
Administration
Noninfectious risks
Infectious Risks
Noninfectious Risks
Blood
Conservation
Strategies
Disorders of
Hemostasis:
Diagnosis and
Treatment
Disorders of
Disorders of Primary
Hemostasis: Hemostasis
Diagnosis and
Treatment Disorders of Secondary
Hemostasis

Hereditary Hypercoagulability

Acquired Disorders of
Hemostasis
Disorders of Primary Hemostasis

• Bernard-Soulier Syndrome
autosomal recessive disorder
abnormality of the Gp Ib receptor
qualitative and quantitative dysfunction that impairs platelet adhesion
to exposed vWF at the site of vascular injury
• Glanzmann Thrombasthenia
autosomal recessive
defect in the platelet integrim αIIbβ3 receptor
defective platelet aggregation
Disorders of Primary Hemostasis
• von Willebrand Disease
most common hereditary bleeding disorder
factor deficiency with clinical features of platelet dysfunction
vWF levels correlate with FVIII levels
mucocutaneous bleeding, menorrhagia, and prolonged bleeding from
minor wounds and dental extractions
criteria for diagnosis:
 hx of mucosal bleeding or prolonged bleeding after dental extractions, surgical
procedures, or postpartum hemorrhage
 family hx of bleeding disorders
 reduced activity of vWF
primary treatment options: DDAVP and factor concentrates
Disorders of Secondary Hemostasis

• Hemophilias
Hemophilia A: most common form; FVIII deficiency; X-linked
recessive
Hemophilia B: “Christmas disease”; second most common type;
factor IX deficiency; X-linked recessive
Hemophilia C: very rare; FXI deficiency; autosomal recessive
Tx: plasma transfusion or factor concentrates
Acquired haemophilia: develops in association with connective
tissue disorders, pregnancy, or malignancy
 development of antibodies to FVIII
 subcutaneous bleeding episodes and soft tissue hematomas (vs hemarthroses
in congenital hemophilia
Hereditary Hypercoagulability

• FVL mutation
Tx: lifelong therapeutic anticoagulation
• Protein C and S deficiencies
Warfarin: long-term management
 started slowly once the patient is therapeutic on heparin to avoid risk of warfarin
limb necrosis
Acquired Disorders of Hemostasis

• Vitamin K Deficiency
Vitamin K: essential for fat-soluble vitamins
 for FII, VII, IX, X, protein C and S
K1 (phylloquinone): leafy greens
K2 (menaquinone): synthesized in the GI tract by intestinal bacteria
and accounts for the bulk of vitamin K stored in the liver
d/t liver insufficiency, sterile gut of the newborns and oral antibiotic
treatments
prolonged PT and aPTT
Tx: vit K replacement
Acquired Disorders of Hemostasis

• Liver Disease
presents with bleeding complications, including CNS hemorrhage or
GI bleeding
bleeding diathesis can be d/t endothelial dysfunction, portal
hypertension, thrombocytopenia, and procoagulant imbalance
results in deficiencies of FII, V, VII, IX, X and XI
Acquired Disorders of Hemostasis

• Disseminated Intravascular Coagulopathy

systemic activation of coagulation
associated with comorbid condition such as infection, inflammation or
malignancy
clinical presentation ranges from thromboembolism and organ
dysfunction to consumptive coagulopathy and major bleeding
mainstay of management: supportive care and treatment of the
underlying disorder
severe cases of major hemorrhage or ischemic organ failure: factor
and fibrinogen replacement, anticoagulation, or pharmacologic
therapies
Common Disorders Associated with
Disseminated Intravascular
Coagulation
Acquired Disorders of Hemostasis

• Disseminated Intravascular Coagulopathy

Dx: compilation of prolonged PT and aPTT, thrombocytopenia,
hypofibrinogenemia, and increasing fibrin degradation products with
associated condition
Tx
 consumptive coagulopathy and thrombocytopenia with clinical signs of bleeding:
transfusion of plasma and platelets respectively
 Plasma: mainstay of replacement therapy for consumption of clotting factors (10
to 15 mL/kg)
 Cryoprecipitate: product of choice for overt DIC with consumptive coagulopathy
and major bleeding
Acquired Disorders of Hemostasis
• Disseminated
Intravascular
Coagulopathy

arterial and venous

thromboembolism
 more concerning than
hemorrhage in DIC with
evidence of acute organ
dysfunction
 Tx: therapeutic
anticoagulation
Anticoagulation
and Pharmacologic
Therapy
Anticoagulation Anticoagulation Regimens and
and Pharmacologic Associated Anesthetic Concerns

Therapy
Recombinant Activated Factor VII

Prothrombin Complex
Concentrates

Desmopressin

Antifibrinolytic Therapy
Anticoagulation Regimens and
Associated Anesthetic Concerns
• Antiplatelet therapy: indicated for patients at risk for cerebral
vascular accident, myocardial infarction, or other vascular
thrombosis complications
• Mechanisms for platelet dysfunction
COX inhibition
PDE inhibition
ADP receptor antagonism
GP IIb/IIIa receptor antagonism
Anticoagulation Regimens and
Associated Anesthetic Concerns
• Cyclooxygenase Inhibitors
COX-1
 maintaining the integrity of gastric lining, renal blood flow and initiation the
formation of TxA2
 inhibition: risk for bleeding and GI and renal morbidity
COX-2
 synthesizing the prostaglandin mediators of pain and inflammation
Anticoagulation Regimens and
Associated Anesthetic Concerns
• Cyclooxygenase Inhibitors
Aspirin
 noncompetitive and irreversible inhibitor of both COX enzymes
 effects last the lifetime of the affected platelets
 DDAVP: improves platelet function in the presence of aspirin
NSAIDs
 competitive antagonists
 effects last only as long as the drug’s time to elimination
 nonselective: Naprosyn and Ibuprofen
 selective COX-2 inhibitors: Celecoxib
Anticoagulation Regimens and
Associated Anesthetic Concerns
• Phosphodiesterase Inhibitors
for stroke prophylaxis
increase the production of cAMP
Dipyridamole: reversible ADP reuptake inhibitor and the prime
therapeutic agent in this class
others: Caffeine, Aminophylline and Theophylline
Anticoagulation Regimens and
Associated Anesthetic Concerns
• ADP Receptor Antagonists
prevent the expression of GP IIb/IIIa on the surface of activated
platelets
to prevent MI and in-stent thrombosis in coronary artery disease
to inhibit thromboembolism in CVD and PAD
Clopidogrel: MC; noncompetitive and irreversible antagonist
Anticoagulation Regimens and
Associated Anesthetic Concerns
• GP IIb/IIIa Receptor Antagonists
inhibit the cross-linkage of fibrinogen
Abciximab: monoclonal antibody
Tirofiban and Eptifibatide: simulate the binding site of fibrinogen
Vorapaxar
 PAR-1 antagonist
 reversible agent with a very long half-life (3 to 4 days)
 for patients with significant renal insufficiency
Anticoagulation Regimens and
Associated Anesthetic Concerns
• Vitamin K Antagonists
Warfarin
 for management of hypercoagulable disorders, venous thromboembolism, and
stroke prophylaxis in patients with atrial fibrillation, artificial heart valves, or
mechanical assist devices
 competes with vitamin K for carboxylation-binding sites
 inhibits synthesis of vit K-dependent clotting factors as well as protein C and S
Anticoagulation Regimens and
Associated Anesthetic Concerns
• New Oral Anticoagulants
Anticoagulation Regimens and
Associated Anesthetic Concerns
• Heparin Therapy
one of the oldest and most common anticoagulation regimens
Two forms:
 UFH: indirectly inhibits thrombin and Fxa by binding to AT-III, causing a
conformational shape change which significantly increases its activity
 for immediate anticoagulation with ACS, pulmonary embolism and during
cardiopulmonary bypass or vascular surgery
 LMWH: fractionated form of heparin with similar mechanism of action but with
more specific inhibition of FXa
 enoxaparin, dalteparin and reviparin
 preferred over UFH for both DVT prophylaxis and treatment
Anticoagulation Regimens and
Associated Anesthetic Concerns
• Heparin-Induced Thrombocytopenia
clinical disorder that develops after extended heparin therapy
associated with significant organ failure, vascular compromise and
mortality from thromboembolic complications
UFH is more likely than LMWH to lead to immune complexes
HIT1: mild thrombocytopenia, benign and does not involve immune
complexes
HIT2: immune-mediated response and carries a significant risk of
hypercoagulability
Anticoagulation Regimens and
Associated Anesthetic Concerns
• Indirect Factor Xa Antagonist
Fondaparinux
 highly specific antagonist for free FXa that also acts by binding with AT-III
 for DVT treatment and prophylaxis
 undergoes renal elimination
 no available antidote in the event of bleeding or need for emergency procedures
Anticoagulation Regimens and
Associated Anesthetic Concerns
• Parenteral Direct Thrombin Inhibitors
directly inhibit thrombin in its free and fibrin-bound states
not immunogenic and no risk of HIT
reversal depends on clearance
for patients with HIT who suffer frim concurrent renal failure
Argatroban: prolong the INR and aPTT
Bivalirudin: short-acting DTI with rapid onset of action and renal
excretion
 DOC for patients with both renal and hepatic dysfunction
 good agent for use during cardiopulmonary bypass in patients with HIT
Recombinant Activated Factor VII

• for prophylaxis and treatment of patients with hemophilia A or B

complicated by inhibitors to FVIII and FIX concentrates
• for treatment of acquired hemophilia and FVII deficiency
• off-label use for the prevention and treatment of coagulopathy and
major blood loss in patients with postpartum hemorrhage, trauma,
reversal of various anticoagulants, and high-risk cardiac surgery
• major adverse effects: arterial and venous thromboembolism
• main contraindications: DIC and high thromboembolism risk
Prothrombin Complex Concentrates

• for treatment of hemophilia and reversal of vit K antagonists

• first-line agents for reversal of NOACs
• DOC for immediate reversal of oral anticoagulants in place of
rFVIIa and FFP
• has a potential to generate significant thrombin burst
Desmopressin (DDAVP)

• synthetic analogue for the endogenous ADH, vasopressin

• acts at the V2 receptor in nephron and endothelial cells
• one of the DOC for treatment of mild bleeding in patients with
vWD and mild hemophilia A
• causes the release of FVIII and vWF from with vascular
endothelial cells
• dosage: 0.3 µg/kg IV over 20 to 30 mins
Antifibrinolytic Therapy

• Types
Lysine analogues
 EACA
 TXA
Nonspecific serine protease inhibitor
 Aprotinin: prevents action of trypsin, plasmin and kallikrein
Thank you!